Abstract

In 1997 Congress created the Sustainable Growth Rate (SGR) formula for the payment of physicians under Part B of Medicare. SGR established a target rate of growth for aggregate costs of physician services under Part B, linked to growth in overall GDP. If growth in aggregate Part B costs exceeds the target, the rate at which physicians are paid in the following year is to be reduced by a corresponding amount. In SGR, Congress and the U.S. medical profession jointly confront a policy dilemma with no clear solution. For several years running, Congress has elected to postpone cuts in payment to physicians required under SGR. Absent further Congressional action, in 2013 physicians' fees under Part B of Medicare will be reduced by more than 30 %. The historical roots of SGR suggest that a potential solution lies in shifting to regional expenditure targets-an approach applied successfully in Canada in the 1970s when Canadian Medicare confronted rising physician fees. The commission that created what was to become SGR was aware of the lessons learned in Canada, and recommended that they also be applied to U.S. Medicare.

Mexican Immigrants in the US Living Far from the Border may Return to Mexico for Health ServicesJOURNAL OF IMMIGRANT AND MINORITY HEALTHBergmark, R., Barr, D., Garcia, R.2010; 12 (4): 610-614

Abstract

This study explores to what extent and why Mexican immigrants in the U.S. living far from the border return to Mexico for medical services.Structured Spanish-language qualitative interviews were completed with a crosssectional sample of 10 Central Mexican immigrants living in Northern California and with 10 physicians and 25 former immigrants living in Central Mexico.Sixteen of the 35 current and former immigrants (46%) said they or a close friend or relative had returned to Mexico from the U.S. for health-related reasons. Participants returned to Mexico for care due to unsuccessful treatment in the U.S., the difficulty of accessing care in the U.S. and preference for Mexican care.Obtaining care in Mexico appears to be common. These findings have implications for the maintenance of continuity of care, for Mexico's healthcare system, and for the impact of changing border policies on immigrant health.

Abstract

Previous research has documented that negative experiences in chemistry courses are a major factor that discourages many students from continuing in premedical studies. This adverse impact affects women and students from under-represented minority (URM) groups disproportionately. To determine if chemistry courses have a similar effect at a large public university, we surveyed 1,036 students from three entering cohorts at the University of California, Berkeley. We surveyed students at the beginning of their first year at the university and again at the end of their second year. All subjects had indicated an interest in premedical studies at the time they entered the university. We conducted follow-up interviews with a stratified sub-set of 63 survey respondents to explore the factors that affected their level of interest in premedical studies. Using a 10-point scale, we found that the strength of interest in premedical studies declined for all racial/ethnic groups. In the follow-up interviews, students identified chemistry courses as the principal factor contributing to their reported loss of interest. URM students especially often stated that chemistry courses caused them to abandon their hopes of becoming a physician. Consistent with reports over more than 50 years, it appears that undergraduate courses in chemistry have the effect of discouraging otherwise qualified students, as reflected in their admission to one of the most highly selective public universities in the US, from continuing in premedical studies, especially in the case of URM students. Reassessment of this role for chemistry courses may be overdue.

Abstract

To determine the causes among underrepresented racial and ethnic minority groups (URM) of a decline in interest during the undergraduate years in pursuing a career in medicine.From fall 2002 through 2007, the authors conducted a longitudinal study of 362 incoming Stanford freshmen (23% URM) who indicated on a freshman survey that they hoped to become physicians. Using a 10-point scale of interest, the authors measured the change in students' levels of interest in continuing premedical studies between the beginning of freshman year and the end of sophomore year. Follow-up interviews were conducted with 68 participants, approximately half of whom had experienced decreases in interest in continuing as premeds, and half of whom who had experienced increases in interest.URM students showed a larger decline in interest than did non-URM students; women showed a larger decline than did men, independent of race or ethnicity. The authors found no association between scholastic ability as measured by SAT scores and changes in level of interest. The principal reason given by students for their loss of interest in continuing as premeds was a negative experience in one or more chemistry courses. Students also identified problems in the university's undergraduate advising system as a contributor.Largely because of negative experiences with chemistry classes, URM students and women show a disproportionate decline in interest in continuing in premedical studies, with the result that fewer apply to medical school.

Planning services for the homeless in the San Francisco PeninsulaJOURNAL OF HEALTH CARE FOR THE POOR AND UNDERSERVEDOsterberg, L. G., Barr, D. A.2007; 18 (4): 749-756

Abstract

A survey of clients seeking homeless services at agencies in the SF Peninsula, indicates that a disproportionate percentage are minority group members (African American and Hispanic) and veterans, and points to the need for integrated housing, social services, and health care for this vulnerable population.

Ethics in public health research: a research protocol to evaluate the effectiveness of public-private partnerships as a means to improve health and welfare systems worldwide.American journal of public healthBarr, D. A.2007; 97 (1): 19-25

Abstract

Public-private partnerships have become a common approach to health care problems worldwide. Many public-private partnerships were created during the late 1990s, but most were focused on specific diseases such as HIV/AIDS, tuberculosis, and malaria. Recently there has been enthusiasm for using public-private partnerships to improve the delivery of health and welfare services for a wider range of health problems, especially in developing countries. The success of public-private partnerships in this context appears to be mixed, and few data are available to evaluate their effectiveness. This analysis provides an overview of the history of health-related public-private partnerships during the past 20 years and describes a research protocol commissioned by the World Health Organization to evaluate the effectiveness of public-private partnerships in a research context.

Abstract

As Vietnam opens its economy to privatization, its system of healthcare will face a series of crucial tests. Vietnam's system of private healthcare--once comprised only of individual physicians holding clinic hours in their homes--has come to also include larger customer-oriented clinics based on an American business model. As the two models compete in the expanding private market, it becomes increasingly important to understand patients' perceptions of the alternative models of care. This study reports on interviews with 194 patients in two different types of private-sector clinics in Vietnam: a western-style clinic and a traditional style, after-hours clinic. In bivariate and multivariate analyses, we found that patients at the western style clinic reported both higher expectations of the facility and higher satisfaction with many aspects of care than patients at the after-hours clinic. These different perceptions appear to be based on the interpersonal manner of the physician seen and the clinic's delivery methods rather than perceptions of the physician's technical skill and method of treatment. These findings were unaffected by the ethnicity of physician seen. These findings suggest that patients in Vietnam recognize and prefer more customer-oriented care and amenities, regardless of physician ethnicity and perceive no significant differences in technical skill between the private delivery models.

The practitioner's dilemma: Can we use a patient's race to predict genetics, ancestry, and the expected outcomes of treatment?ANNALS OF INTERNAL MEDICINEBarr, D. A.2005; 143 (11): 809-815

Abstract

Recent research has identified genetic traits that can be used in a laboratory setting to distinguish among global population groups. In some genetic analyses, the population groups identified resemble groups that are historically categorized as "races." On the basis of these associations, some researchers have argued that a patient's race can be used to predict underlying genetic traits and from these traits, the expected outcomes of treatment. Others have questioned the use of race in this way, arguing that racially defined groups are so heterogeneous that predictions of individual characteristics derived from group averages are bound to be problematic. Practitioners today face the dilemma of translating this scientific debate into clinical decisions made 1 patient at a time. Is it or is it not appropriate to use a patient's self-identified "race" to help decide treatment? In contrast to the global population groups identified by genetic studies, the U.S. population has experienced substantial genetic admixture over time, weakening our ability to distinguish groups on the basis of meaningful genetic differences. Nonetheless, many researchers have suggested that these differences are still sufficient to identify racially specific uses for pharmaceutical and other treatments. A review of recent research on the treatment of hypertension and congestive heart failure finds that race-specific treatments of this type carry a substantial risk for treating patients--black or white--inappropriately, either by withholding a treatment that may be effective or by using a treatment that may be ineffective. Only by moving beyond historical concepts of "race" to examining a patient's individual socioeconomic, cultural, behavioral, and ancestral circumstances can a practitioner select the treatment that is most likely to be effective and in doing so, can best serve that patient's needs.

Abstract

Full access to medical care includes cultural and linguistic access as well as financial access. We sought to identify cultural and linguistic characteristics of low-income, ethnic minority patients' recent encounters with health care organizations that impede, and those that increase, health care access.We conducted four focus groups with ethnically homogeneous African American, Latino, Native American, and Pacific Islander patients. Study participants were "walked" through the stages of a medical encounter and asked to identify physician and staff behaviors that made the patient feel more comfortable (a surrogate for increasing access) and behaviors that made the patient feel less comfortable (a surrogate for decreasing access).African American and Native American patients in particular expressed overall satisfaction with their physicians' services. Patients from all groups saw nonphysician staff as frequently impeding access. Based on perceptions of negative stereotypes, Native American and Pacific Islander patients reported hostility toward physicians' efforts at prevention and patient education.For the ethnic minority patients in our study, most perceived that cultural impediments to access involved nonphysician staff. Closer collaborations between health care organizations and ethnic minority communities in the recruitment and training of staff may be needed to improve cultural and linguistic access to care.

Race/ethnicity and patient satisfaction - Using the appropriate method to test for perceived differences in care130th Annual Meeting of the American-Public-Health-AssociationBarr, D. A.SPRINGER.2004: 937–43

Abstract

To determine whether an established patient satisfaction scale commonly used in the primary care setting is sufficiently sensitive to identify racial/ethnic differences in satisfaction that may exist; to compare a composite indicator of overall patient satisfaction with a 4-item satisfaction scale that measures only the quality of the direct physician-patient interaction.Real-time survey of patients during a primary care office visit.Private medical offices in a generally affluent area of northern California.Five hundred thirty-seven primary care patients selected at random from those entering a medical office.Patient satisfaction using 1) a composite, 9-item satisfaction scale (VSQ-9); and 2) a 4-item subset of that scale that measures only satisfaction with direct physician care.The 9-item, composite scale identified no significant difference in patient satisfaction between white and nonwhite patients, after controlling for patient demographics and other aspects of the visit. The 4-item, physician-specific scale indicated that nonwhite patients were less satisfied than white patients with their direct interaction with the physicians included in the study (P =.01).Measurements of patient satisfaction that use multi-item, composite indicators should also include focused comparisons of satisfaction directly with the care provided by the physician. In measurements of patient satisfaction, patient race/ethnicity should be included as an explanatory variable. The results also confirm earlier findings that factors external to the direct physician-patient interaction can have substantial effects on patients' perceptions of that interaction.

Abstract

As health care in the United States evolves increasingly toward managed care, there are continuing concerns about maintaining the quality of the physician-patient interaction, of which patient satisfaction is one measure. A quality assessment tool that measures both patient satisfaction with care and the ways organizational factors affect satisfaction will enable clinicians and administrators to redesign the care process accordingly. SURVEY METHODOLOGY: The measure of the quality of a physician office visit includes both the administration of a standardized satisfaction instrument and direct observation of the patient throughout the care process. This methodology was tested in 1997-1998 on an initial sample of 291 patients at a large multispecialty medical group in northern California. The surveyor recorded objective characteristics of the visit, surveyed patients about their impression of certain aspects of the visit related to satisfaction, and administered a standardized visit satisfaction survey. A second set of control patients who visited the same physician on the same day was contacted by phone and given the satisfaction survey two to four weeks later.Patients readily accepted the presence of a surveyor during their visit, with an overall response rate of 78%. While patients contacted retrospectively gave lower satisfaction ratings, the presence of a surveyor did not affect patients' satisfaction responses. Data obtained by using the concurrent methodology provides significant information about organizational factors influencing patient satisfaction.Measuring patient satisfaction concurrently during a physician office visit offers an attractive alternative to other methods of measuring this key aspect of quality.

The current state of health care in the former Soviet Union: Implications for health care policy and reformAMERICAN JOURNAL OF PUBLIC HEALTHBARR, D. A., Field, M. G.1996; 86 (3): 307-312

Abstract

Given the many profound health care problems facing Russia and the other former Soviet republics, there are a number of fundamental policy questions that deserve close attention as part of the reform process.Summary data regarding Soviet health care issues were drawn from government agency reports, scholarly books and journals, recent press reports, and the authors' personal research.Smoking, alcohol, accidents, poor sanitation, inadequate nutrition, and extensive environmental pollution contribute to illness and premature mortality in Russia and the other newly independent states. Hospitals and clinics are poorly maintained and equipped; most physicians are poorly trained and inadequately paid; and there is essentially no system of quality management. While efforts at reform, which emphasize shifting to a system of "insurance medicine," have been largely unsuccessful, they have raised several important policy issues that warrant extensive research and discussion.Without considering the implications and consequences of alternative policy directions, Russia and the other states face the very real possibility of developing health care systems that improve the overall level of care but also incorporate limited access and escalating costs. Russian health care reform leaders can learn from the health care successes in the West and avoid repeating our mistakes.

Abstract

To study and report the attitudes and practices of physicians in a former Soviet republic regarding issues pertaining to patients' rights, physician negligence and the acceptance of gratuities from patients.Survey questionnaire administered to physicians in 1991 at the time of the Soviet breakup.Estonia, formerly a Soviet republic, now an independent state. SURVEY SAMPLE: A stratified, random sample of 1,000 physicians, representing approximately 20 per cent of practicing physicians under the age of 65.Most physicians shared information with patients about treatment risks and alternatives, with the exception of cancer patients: only a third of physicians tell the patient when cancer is suspected. Current practice at the time of the survey left patients few options when physician negligence occurred; most physicians feel that under a reformed system physician negligence should be handled within the local facility rather than by the government. It was common practice for physicians to receive gifts, tips, or preferential access to scarce consumer goods from their patients. Responses varied somewhat by facility and physician nationality.The ethics of Soviet medical practice were different in a number of ways from generally accepted norms in Western countries. Physicians' attitudes about the need for ethical reform suggest that there will be movement in Estonia towards a system of medical ethics that more closely approximates those in the West.

Abstract

After World War I, medical education in the Soviet Union and medical education in the United States headed in strikingly divergent directions. In keeping with the recommendations of the Flexner report, medical education in the United States became a university-based academic discipline based in the natural sciences. In contrast, the Soviet Union created a series of free-standing medical institutes whose admission, curricular, and pedagogic policies were centrally controlled in strict conformity with political doctrine. Notable features of the Soviet system were narrowly defined professional education; early specialization, beginning in the first year of medical school; and emphasis on empirical clinical training at the expense of scientifically based education. Despite the historical differences between Soviet and American medical education, there are several issues that face present-day medical educators in both the United States and the Soviet successor states. These include an overabundance of specialists, the need to provide equitable professional opportunities for physicians of both sexes, and the need to provide access to medical education for qualified candidates from underrepresented social or ethnic groups or from geographically remote regions.

Abstract

The advent of managed care in the United States brings with it more and larger organizations involved in providing primary care. Studies of organizations in general suggest that large managed care organizations will have difficulty providing high-quality primary care largely because of their complexity and the fragmentation of their work force. Existing data confirm that these organizations have shortcomings in both patient and physician satisfaction. There are few data to indicate whether such organizations can mitigate these problems by saving costs through economies of scale. To offset their inherent weaknesses, large primary care organizations need to ensure patients' accessibility to their physicians, the continuity of the physician-patient relationship, a care environment conducive to a high-quality physician-patient interaction, and the clinical autonomy of physicians. Much additional research needs to be done to further understand these issues.